Effect of Psychiatric Illness on Acute Care Utilization at End of Life From Serious Medical Illness

Kyle Lavin; Dimitry S Davydow; Lois Downey; Ruth A Engelberg; Ben Dunlap; James Sibley; William B Lober; Kelson Okimoto; Nita Khandelwal; Elizabeth T Loggers; Joan M Teno; J Randall Curtis

doi:10.1016/j.jpainsymman.2017.04.003

Effect of Psychiatric Illness on Acute Care Utilization at End of Life From Serious Medical Illness

J Pain Symptom Manage. 2017 Aug;54(2):176-185.e1. doi: 10.1016/j.jpainsymman.2017.04.003. Epub 2017 May 9.

Authors

Affiliations

¹ Department of Psychiatry and Palliative Care Program, University of North Carolina, Chapel Hill, North Carolina, USA.
² Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, Washington, USA.
³ Cambia Palliative Care Center of Excellence, University of Washington, Seattle, Washington, USA; Division of Pulmonary, Critical Care and Sleep Medicine, University of Washington, Seattle, Washington, USA.
⁴ Cambia Palliative Care Center of Excellence, University of Washington, Seattle, Washington, USA; Department of Bioinformatics and Medical Education, University of Washington, Seattle, Washington, USA.
⁵ Cambia Palliative Care Center of Excellence, University of Washington, Seattle, Washington, USA.
⁶ Cambia Palliative Care Center of Excellence, University of Washington, Seattle, Washington, USA; Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, Washington, USA.
⁷ Cambia Palliative Care Center of Excellence, University of Washington, Seattle, Washington, USA; Division of Medical Oncology, University of Washington, Seattle, Washington, USA; Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington, USA.
⁸ Cambia Palliative Care Center of Excellence, University of Washington, Seattle, Washington, USA; Division of Gerontology and Geriatrics, University of Washington, Seattle, Washington, USA.
⁹ Cambia Palliative Care Center of Excellence, University of Washington, Seattle, Washington, USA; Division of Pulmonary, Critical Care and Sleep Medicine, University of Washington, Seattle, Washington, USA. Electronic address: [email protected].

PMID: 28495487
DOI: 10.1016/j.jpainsymman.2017.04.003

Abstract

Context: Little is known about psychiatric illness and utilization of end-of-life care.

Objectives: We hypothesized that preexisting psychiatric illness would increase hospital utilization at end of life among patients with chronic medical illness due to increased severity of illness and care fragmentation.

Methods: We reviewed electronic health records to identify decedents with one or more of eight chronic medical conditions based on International Classification of Diseases-9 codes. We used International Classification of Diseases-9 codes and prescription information to identify preexisting psychiatric illness. Regression models compared hospital utilization among patients with and without psychiatric illness. Path analyses examined the effect of severity of illness and care fragmentation.

Results: Eleven percent of 16,214 patients with medical illness had preexisting psychiatric illness, which was associated with increased risk of death in nursing homes (P = 0.002) and decreased risk of death in hospitals (P < 0.001). In the last 30 days of life, psychiatric illness was associated with reduced inpatient and intensive care unit utilization but increased emergency department utilization. Path analyses confirmed an association between psychiatric illness and increased hospital utilization mediated by severity of illness and care fragmentation, but a stronger direct effect of psychiatric illness decreasing hospitalizations.

Conclusion: Our findings differ from the increased hospital utilization for patients with psychiatric illness in circumstances other than end-of-life care. Path analyses confirmed hypothesized associations between psychiatric illness and increased utilization mediated by severity of illness and care fragmentation but identified more powerful direct effects decreasing hospital use. Further investigation should examine whether this effect represents a disparity in access to preferred care.

Keywords: Palliative care; end-of-life care; epidemiology; multimorbidity; psychiatric illness.

MeSH terms

Chronic Disease / mortality*
Chronic Disease / psychology
Chronic Disease / therapy*
Cohort Studies
Critical Care / statistics & numerical data
Emergency Medical Services / statistics & numerical data
Female
Hospitalization
Humans
Male
Mental Disorders / complications*
Mental Disorders / mortality
Mental Disorders / therapy
Middle Aged
Palliative Care / psychology
Palliative Care / statistics & numerical data*
Regression Analysis
Risk Factors
Severity of Illness Index
Terminal Care / psychology
Terminal Care / statistics & numerical data*