Care of Adults With Mental Health and Substance Abuse Disorders in U.S. Community Hospitals

Care of Adults With Mental Health and Substance Abuse Disorders in U.S. Community Hospitals, 2004
Executive Summary
Mental health and substance abuse (MHSA) disorders place a substantial burden on individuals, families, the health care system, and the economy. Beyond the personal costs of these conditions, mental illness and substance abuse result in lost productivity, increased medical expenditures, and other costs including those resulting from law enforcement activities.

Community hospitals play an important role in the treatment of individuals with MHSA disorders. For some of these patients, the MHSA disorder is the principal diagnosis, or the main reason for the hospital stay. For others, the MHSA disorder complicates a principal non-MHSA diagnosis and is listed on the hospital record as a secondary diagnosis. In 2004, 24 percent of stays in community hospitals were for patients with principal and/or secondary MHSA diagnoses.

In 2004, adults with a mental health and/or substance abuse diagnosis accounted for 1 out of 4 stays at U.S. community hospitals—7.6 million hospital stays.

This Fact Book examines community hospital care for adults 18 years of age and older with MHSA diagnoses. Community hospitals are non-Federal, short-term (or acute care) general and specialty hospitals. They include any type of hospital that is open to the public, such as academic medical centers, medical specialty hospitals, and public hospitals, but they do not include specialty psychiatric or substance abuse treatment facilities.

This Fact Book provides an overview of hospital stays involving MHSA disorders and addresses these key questions:

■What are the common reasons for hospitalization, by type and diagnosis?
■How do stays vary by gender and age?
■How are patients admitted to the hospital?
■What is the mean length of stay?
■How much do hospital stays cost?
■What percentage of hospital resource use is attributable to MHSA disorders?
■Who is billed for hospital stays?
■Where do patients go after they are discharged?
In addition, this Fact Book presents detailed statistics on three special topics related to MHSA hospitalizations:

■Dual diagnosis stays (i.e., the patient has both a substance-related and a mental health disorder).
■Stays related to suicide or attempted suicide.
■Maternal stays complicated by a mental health or substance abuse disorder.
Eleven mutually exclusive categories of MHSA disorders are examined in this Fact Book:

•Mood disorders.
•Substance-related disorders.
•Delirium, dementia, and amnestic and cognitive disorders.
•Anxiety disorders.
•Schizophrenia and other psychotic disorders.
•Personality disorders.
•Adjustment disorders.
•Disruptive behavior disorders.
•Impulse control disorders.
•Disorders usually diagnosed in infancy, childhood, and adolescence.
•Miscellaneous mental disorders.
What Are the Common Reasons for Hospitalization, by Type and Diagnosis?
In 2004, nearly 1 out of 4 hospital stays for adults in U.S. community hospitals involved MHSA disordersi—about 7.6 million hospitalizations. Of these, 1.9 million hospitalizations (6 percent of adult hospital stays) had a principal MHSA diagnosis and 5.7 million (18 percent) were primarily for non-MHSA diagnoses but had a secondary mental health or substance abuse diagnosis.

The top 5 MHSA diagnosesii seen in the hospital were mood disorders, substance-related disorders, delirium/dementia, anxiety disorders, and schizophrenia. One out of every 10 hospital stays included a diagnosis of mood disorders (over 3.3 million stays). One out of every 14 hospital stays included substance-related disorders (2.3 million stays). One out of every 20 stays was related to delirium/dementia (1.7 million stays).


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iBased on all-listed diagnoses.
iiBased on all-listed MHSA diagnoses.


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How Do Stays Vary by Gender and Age?
Gender
There were more MHSA-related hospital stays for women than for men. Although women comprised 51 percent of the U.S. adult population, they accounted for 58 percent of MHSA-related stays and 62 percent of non-MHSA stays. The most frequent MHSA diagnosis among hospitalized women was mood disorders. Substance abuse was the most frequent MHSA diagnosis in the hospital for men. Substance-related disorders were 3 times more common among hospitalized men than women.

Age
Older age groups accounted for a disproportionate share of hospital stays for MHSA disorders in 2004. For example, adults 80 and older comprised 5 percent of the U.S. adult population, yet they accounted for nearly 21 percent of MHSA hospital stays. In contrast, adults ages 18 to 44 comprised over half the total U.S. population, but accounted for 30 percent of MHSA hospital stays.

Among adults younger than 80, the most common MHSA diagnosis was mood disorders. Overall, 11 percent of stays for people 18-44 years of age, 13 percent of those 45-64 years of age, and 8 percent of those 65-79 years of age included a diagnosis of mood disorders. For adults 80 and older, delirium/dementia was the most common MHSA diagnosis; this disorder was noted in 21 percent of hospital stays for this age group, but mood disorders ranked second for this age group (8 percent of stays).

The second most common MHSA diagnosis for adults ages 18-64 was substance-related disorders, which was noted in about 10 percent of all hospital stays for this age group.

The distribution of age varied by the top 5 most common MHSA diagnoses. Almost half of all substance-related stays were for adults ages 18-44 while nearly all (93 percent) of the stays related to dementia/delirium were for adults age 65 and older.

One out of every 10 hospital stays included a diagnosis of mood disorders.

One out of every 14 hospital stays involved substance-related disorders.

The most frequent MHSA diagnosis among hospitalized women was mood disorders.

The most frequent MHSA diagnosis for men was substance-related disorders. Substance-related disorders were 3 times more common among hospitalized men than women.

Adults 80 and older comprised 5 percent of the U.S. adult population, yet they accounted for 21 percent of MHSA hospital stays.


How Are Patients Admitted to the Hospital?
Nearly 61 percent of MHSA-related admissions occur through the emergency department (ED) compared to only 45 percent of admissions with no MHSA diagnosis.

Adults with only secondary MHSA diagnoses were the most likely to be admitted through the ED—64 percent—compared with 51 percent for admissions with principal MHSA diagnoses only.

What Is the Mean Length of Stay?
Adults with any MHSA diagnosis (principal or secondary) stayed in the hospital longer than adults with non-MHSA diagnoses (5.8 versus 4.5 days). The difference was even more pronounced for adults with only a principal MHSA diagnosis—they stayed in the hospital an average of 8 days compared with 5 days for patients with non-MHSA diagnoses.

How Much Do Hospital Stays Cost?
Cost, by Type
The mean total cost for a hospital stay with any MHSA diagnosis ($7,800) was $1,100 lower than for stays with no MHSA diagnosis ($8,900). The mean cost per day for MHSA hospitalizations also was lower than for non-MHSA hospital stays—$1,600 per day compared with $2,300 per day—indicating that MHSA stays were less resource intensive.

The difference in cost was even more pronounced for adults with only a principal MHSA diagnosis. The mean total cost for a hospital stay with only a principal MHSA diagnosis was 39 percent lower than non-MHSA stays ($6,400 versus $8,900), and costs per day were 171 percent lower ($900 versus $2,300).

Cost, by Principal Diagnosis
Hospitalizations for the 5 most common principal MHSA diagnoses—mood disorder, schizophrenia, substance-related disorders, dementia/delirium, and anxiety disorders—cost $9.9 billion nationally.

The most common principal MHSA diagnosis—mood disorders—had the highest aggregate inpatient hospital costs of all MHSA diagnoses at $3.4 billion nationally in 2004. On a per stay basis, schizophrenia was the most expensive of the common principal MHSA diagnoses to treat at $8,000 per stay.

Hospitalizations for the 5 most common principal MHSA diagnoses cost $9.9 billion nationally.
About 33 percent of all uninsured stays, 29 percent of Medicaid stays, and 26 percent of Medicare stays were related to MHSA disorders, compared with only 16 percent of privately insured stays.

Over 66 percent of adult hospital stays with MHSA diagnoses were billed to the government in 2004.

Who Is Billed for Hospital Stays?
A large proportion of stays for the uninsured and for patients covered by Medicaid and Medicare were related to MHSA disorders. About 33 percent of all uninsured stays, 29 percent of Medicaid stays, and 26 percent of Medicare stays were related to MHSA disorders. On the other hand, only 16 percent of privately insured stays were related to MHSA disorders.

Expected Primary Payer, by Type
Over 66 percent of adult hospital stays with MHSA diagnoses were billed to the government in 2004. Medicaid was billed for 18 percent of all MHSA-related stays and Medicare was billed for 49 percent of all MHSA stays. In comparison, 57 percent of hospital stays with non-MHSA diagnoses were billed to the government.

Stays for patients with MHSA diagnoses were 36 percent more likely to be billed as uninsured than stays unrelated to MHSA diagnoses. Nearly 8 percent of MHSA stays were uninsured compared with about 5 percent of stays with non-MHSA diagnoses. Patients with both principal and secondary MHSA diagnoses were the most likely to be uninsured—nearly 13 percent compared with 5 percent for patients with non-MHSA diagnoses.

Only about 23 percent of stays with MHSA diagnoses were billed to private health insurance compared with about 37 percent of stays with non-MHSA diagnoses.

Expected Primary Payer, by Principal Diagnosis
Hospital stays related to schizophrenia and those associated with delirium/dementia were the most likely to be billed to the government. Over 78 percent of hospital stays for schizophrenia were billed to the government (35 percent to Medicaid and 44 percent to Medicare). Similarly, 90 percent of hospital stays for delirium/dementia were billed to the government (4 percent to Medicaid and 86 percent to Medicare). Schizophrenia is a qualifying disorder for Medicaid, and delirium/dementia is more frequent among the elderly who are covered by Medicare. In contrast, 53 percent of hospital stays for mood disorders and 52 percent of stays for substance-related disorders were billed to government payers.

Where Do Patients Go After They Are Discharged?
Adults with MHSA disorders were more likely to be transferred to non-acute health care facilities (which include psychiatric facilities, nursing homes, and rehabilitation centers) compared to those with non-MHSA diagnoses. Although only 11 percent of non-MHSA stays ended in transfers to non-acute facilities, 16 percent of stays for a principal MHSA diagnosis ended with such a transfer in 2004. Because of the large proportion of elderly patients with dementia as a secondary diagnosis, 27 percent of hospital stays with only secondary MHSA diagnoses ended with transfer to non-acute health care facilities.

Hospital stays that were principally for MHSA disorders were the least likely to be discharged to home health care. Only 2 percent of hospital stays for principal MHSA diagnoses ended in discharge to home health care, compared with 11 percent of stays with only secondary MHSA diagnoses and 10 percent of non-MHSA stays.

Over 78 percent of hospital stays for schizophrenia and 90 percent of hospital stays for delirium/dementia were billed to the government.
Hospital stays related to MHSA disorders accounted for roughly one-fourth of total resource use: 24 percent of all adult stays, 29 percent of days in the hospital, and 22 percent of total hospital costs.

About 3 percent of all hospital stays (nearly 1 million hospitalizations) involved dual diagnosis—both substance-related and mental health disorder.

Men and adults 18-44 are most likely to have a dual diagnosis—55 percent and 60 percent, respectively.



What Percentage of Hospital Resource Use Is Attributable to MHSA Disorders?
MHSA disorders accounted for roughly one-fourth of total resource use in 2004. MHSA disorders were involved in about 24 percent of all adult hospital stays, 29 percent of days in the hospital, and 22 percent of total hospital costs.

Dual Diagnosis Stays
A person with both a substance-related problem and a mental health disorder is considered to have a dual diagnosis. In 2004, nearly 1 million adult hospital stays involved a dual diagnosis—3 percent of all hospital stays. About 13 percent of all MHSA-related hospital stays involved a dual diagnosis.

Among dual diagnosis stays, 34 percent of patients had alcohol-related problems, 45 percent had drug-related problems, and 22 percent had both alcohol- and drug-related problems. The most frequent mental health disorder associated with substance-related problems was mood disorders (68 percent). All other mental health disorders were much less frequent. Anxiety disorders were seen in about 19 percent of hospital stays with a dual diagnosis and schizophrenia was seen in about 18 percent of these stays.

Most dually diagnosed inpatients were men and were younger. Fifty-five percent of stays with a dual diagnosis were for men, even though 41 percent of other MHSA stays and 38 percent of non-MHSA stays were for men. Similarly, nearly 60 percent of all dually diagnosed inpatients were ages 18-44, even though this age group comprised only 26 percent of other MHSA stays and 33 percent of adult non-MHSA hospital stays.

Hospital stays for dual diagnosis were more likely to be billed as uninsured or billed to Medicaid than to any other payer.

Suicide-Related Stays
In 2004, nearly 179,000 adult hospital stays were related to suicide or suicide attempts. By far, the most frequent mechanism of injury for suicide-related hospitalizations was poisoning. Nearly two-thirds of hospital stays for suicide attempts were a result of poisoning, while 1 in 10 hospital stays for suicide attempts was a result of cutting/piercing. Firearms were implicated in only 1 percent of suicide-related hospital stays.

Nearly all suicide-related hospital stays involved MHSA disorders (93 percent). The single most common MHSA diagnosis related to attempted suicide was mood disorders, which accounted for nearly 70 percent of all suicide-related stays.

Adults hospitalized for suicide attempt were younger than other patients. Most suicide-related hospital stays occurred among adults ages 18-44 (72 percent), followed by adults ages 45-64 (24 percent). Patients ages 65 and older made up less than 4 percent of all suicide-related stays. Uninsured stays and stays billed to Medicaid made up nearly half of all suicide-related hospitalizations. Even though only 5 percent of non-MHSA hospital stays were uninsured, 22 percent of suicide-related stays were uninsured. Nearly 13 percent of non-MHSA hospital stays were billed to Medicaid compared with 23 percent of suicide-related stays.

There were nearly 179,000 adult hospital stays related to suicide or suicide attempts.

Poisoning accounted for 2 out of 3 suicide-related stays—the most frequent mechanism of injury.

Most suicide-related stays (72 percent) were among adults 18-44.

Although only 5 percent of non-MHSA hospital stays were uninsured, 22 percent of suicide-related stays were uninsured.

Five percent of maternal hospital stays involved at least one MHSA disorder.

Medicaid was billed for 38 percent of non-MHSA-related maternal stays but almost 57 percent of MHSA-related maternal stays.



Maternal Stays
In 2004, nearly 4.6 million hospital stays were for women with maternal conditions and of these, 240,000 (5 percent) were complicated by at least one MHSA disorder. Women with MHSA disorders complicating a maternal stay were disproportionately younger, ages 18-24. Even though this group accounted for only 32 percent of non-MHSA-related maternal stays, they were responsible for 40 percent of all MHSA-related maternal stays.

Medicaid was much more likely to be billed for maternal stays complicated by MHSA disorders compared with all other payers. Medicaid was billed for 38 percent of non-MHSA-related maternal stays but almost 57 percent of maternal stays with MHSA disorders.

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Foreword
The mission of the Agency for Healthcare Research and Quality (AHRQ) is to improve the quality, safety, efficiency, and effectiveness of health care for all Americans. To help fulfill this mission, AHRQ develops a number of powerful databases, including those created by the Healthcare Cost and Utilization Project (HCUP). HCUP is a Federal-State-Industry partnership designed to build a standardized, multi-State health data system; HCUP features databases, software tools, and statistical reports to inform policymakers, health system leaders, and researchers.

For data to be useful, they must be disseminated in a timely, accessible way. To meet this objective, AHRQ launched HCUPnet, an interactive, Internet-based tool for identifying, tracking, analyzing, and comparing statistics on hospital utilization, outcomes, and charges (http://www.hcupnet.ahrq.gov/). Menu-driven HCUPnet guides users in tailoring specific queries about hospital care online; with a click of a button, users receive answers within seconds.

To make HCUP data even more accessible, AHRQ disseminates HCUP Statistical Briefs, an online publication series that presents simple, descriptive statistics on a variety of specific, focused topics (http://www.hcup-us.ahrq.gov/reports/statbriefs.jsp). Statistical Briefs are made available regularly throughout the year and have covered topics such as hospitalizations among the uninsured, the national bill for hospital care by payer, and hospitalizations related to childbirth.

In addition, AHRQ produces the HCUP Fact Books to highlight statistics about hospital care in the United States in an easy-to-use, readily accessible format. Each Fact Book provides information about specific aspects of hospital care—the single largest component of our health care dollar. These national estimates are benchmarks against which States and others can compare their own data.

This Fact Book examines inpatient care of mental health and substance abuse (MHSA) disorders. Because HCUP nationwide databases do not include data from long-term care facilities, specialty psychiatric hospitals, or substance-abuse treatment facilities, this report provides a detailed analysis of the treatment of these disorders in short-term, non-Federal, community hospitals. This Fact Book considers MHSA disorders among adults ages 18 and older and offers comprehensive statistics on special topics related to MHSA hospitalizations.

We invite you to tell us how you are using this Fact Book and other HCUP data and tools and to share suggestions on how HCUP products might be enhanced to further meet your needs. Please e-mail us at hcup@ahrq.gov or send a letter to the address below.

Irene Fraser, Ph.D.
Director
Center for Delivery, Organization, and Markets
Agency for Healthcare Research and Quality
540 Gaither Road
Rockville, MD 20850

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Contributors
HCUP is based on data collected by individual State Partner organizations (including State departments of health, hospital associations, and private agencies). These organizations provide the data to AHRQ where the data are converted to uniform data products. Without the participation of the following Partner organizations, HCUP and the 2004 Nationwide Inpatient Sample (NIS) would not be possible:

•Arkansas Department of Health & Human Services
•Arizona Department of Health Services
•California Office of Statewide Health Planning & Development
•Colorado Health and Hospital Association
•Connecticut Integrated Health Information (Chime, Inc.)
•Florida Agency for Health Care Administration
•Georgia Hospital Association (GHA)
•Hawaii Health Information Corporation
•Illinois Department of Public Health
•Indiana Hospital & Health Association
•Iowa Hospital Association
•Kansas Hospital Association
•Kentucky Cabinet for Health and Family Services
•Maryland Health Services Cost Review Commission
•Massachusetts Division of Health Care Finance and Policy
•Michigan Health & Hospital Association
•Minnesota Hospital Association
•Missouri Hospital Industry Data Institute
•Nebraska Hospital Association
•Nevada Department of Human Resources
•New Hampshire Department of Health and Human Services
•New Jersey Department of Health & Senior Services
•New York State Department of Health
•North Carolina Department of Health and Human Services
•Ohio Hospital Association
•Oregon Association of Hospitals and Health Systems
•Rhode Island Department of Health
•South Carolina State Budget & Control Board
•South Dakota Association of Healthcare Organizations
•Tennessee Hospital Association
•Texas Department of State Health Services
•Utah Department of Health
•Vermont Association of Hospitals and Health Systems
•Virginia Health Information
•Washington State Department of Health
•West Virginia Health Care Authority
•Wisconsin Department of Health & Family Services
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Introduction
For those diagnosed with mental health and/or substance abuse (MHSA) disorders, social relationships are strained, and the ability to perform at school and work is impaired. Many are too debilitated to work. The loss of wages is a burden on families and the loss of labor negatively impacts the economy. Moreover, the financial burden of treatment for these chronic conditions is substantial.1-2

Although an untold number of individuals who suffer from MHSA disorders will go untreated, for those who do receive care, treatment settings are varied. Some will seek care in outpatient or ambulatory settings, where the majority of specialty MHSA care takes place. Others will need more intense treatment in an inpatient setting—community hospitals or long-term, residential facilities. With the continued drop in psychiatric beds in specialty facilities, community hospitals have become the primary source of short-term inpatient care.1, 3

This Fact Book examines community hospital stays for adults with MHSA disorders in 2004. MHSA disorders examined in this Fact Book include:

•Mood disorders.
•Substance-related disorders.
•Delirium, dementia, and amnestic and cognitive disorders.
•Anxiety disorders.
•Schizophrenia and other psychotic disorders.
•Personality disorders.
•Adjustment disorders.
•Disruptive behavior disorders.
•Impulse control disorders.
•Disorders usually diagnosed in infancy, childhood or adolescence.
•Miscellaneous mental disorders.
In addition, several special topics are addressed, such as dual diagnosis, hospitalizations for suicide attempt, and maternal stays complicated by MHSA disorders.

Information on data sources and methods are available at the end of the Fact Book. A glossary contains MHSA terms used in this Fact Book. Appendix A provides information on the mapping of diagnostic codes to MHSA disorders. Appendix B provides more detailed information on hospital stays for specific principal MHSA disorders. Appendix C highlights common principal and secondary diagnoses by gender and age.

Treatment in Community Versus Specialty Hospitals
This Fact Book presents information on MHSA stays in U.S. community hospitals, which are defined by the American Hospital Association as “all non-Federal, short-term (or acute care) general and specialty hospitals.”4 Although community hospitals include any type of hospital that is open to the public, such as academic medical centers, medical specialty hospitals, and public hospitals, they do not include specialty psychiatric or substance abuse treatment facilities.

■In 2004, nearly all community hospitals in the United States (98.0 percent) provided care to patients with MHSA disorders.
■Almost one-fourth of adult stays in community hospitals (23.8 percent) involved a MHSA disorder.
■Almost 10 times as many patients with MHSA disorders—7.6 million—were seen in community hospitals as in psychiatric facilities.
■Although specialty psychiatric facilities provided nearly 27 million days of care annually, community hospitals provided over 44 million days of care to patients with MHSA disorders.
■Stays in community hospitals were considerably shorter than stays in specialty facilities. The mean length of stay for MHSA disorders was 5.8 days in community hospitals compared to 33.0 days in specialty psychiatric facilities.