Crowd-out and exposure effects of physical comorbidities on mental health care use: implications for racial-ethnic disparities in access.

Center for Multicultural Mental Health Research, 120 Beacon Street, Somerville, MA 02143, USA.
Health Services Research (Impact Factor: 2.49). 03/2011; 46(4):1259-80. DOI: 10.1111/j.1475-6773.2011.01253.x
Source: PubMed

ABSTRACT In disparities models, researchers adjust for differences in "clinical need," including indicators of comorbidities. We reconsider this practice, assessing (1) if and how having a comorbidity changes the likelihood of recognition and treatment of mental illness; and (2) differences in mental health care disparities estimates with and without adjustment for comorbidities.
Longitudinal data from 2000 to 2007 Medical Expenditure Panel Survey (n=11,083) split into pre and postperiods for white, Latino, and black adults with probable need for mental health care.
First, we tested a crowd-out effect (comorbidities decrease initiation of mental health care after a primary care provider [PCP] visit) using logistic regression models and an exposure effect (comorbidities cause more PCP visits, increasing initiation of mental health care) using instrumental variable methods. Second, we assessed the impact of adjustment for comorbidities on disparity estimates.
We found no evidence of a crowd-out effect but strong evidence for an exposure effect. Number of postperiod visits positively predicted initiation of mental health care. Adjusting for racial/ethnic differences in comorbidities increased black-white disparities and decreased Latino-white disparities.
Positive exposure findings suggest that intensive follow-up programs shown to reduce disparities in chronic-care management may have additional indirect effects on reducing mental health care disparities.


Available from: Benjamin L Cook, Jun 15, 2015
  • [Show abstract] [Hide abstract]
    ABSTRACT: OBJECTIVE Outpatient follow-up after hospitalization for mental health reasons is an important indicator of quality of health systems. Differences among racial-ethnic minority groups in the quality of service use during this period are understudied. This study assessed the quality of outpatient treatment episodes following inpatient psychiatric treatment among blacks, whites, and Latinos in the United States. METHODS The Medical Expenditure Panel Survey (2004-2010) was used to identify adults with any inpatient psychiatric treatment (N=339). Logistic regression models were used to estimate predictors of any outpatient follow-up or the beginning of adequate outpatient follow-up within seven or 30 days following discharge. Predicted disparities were calculated after adjustment for clinical need variables but not for socioeconomic characteristics, consistent with the Institute of Medicine definition of health care disparities as differences that are unrelated to clinical appropriateness, need, or patient preference. RESULTS Rates of follow-up were generally low, particularly rates of adequate treatment (<26%). Outpatient treatment prior to inpatient care was a strong predictor of all measures of follow-up. After adjustment for need and socioeconomic status, the analyses showed that blacks were less likely than whites to receive any treatment or begin adequate follow-up within 30 days of discharge. CONCLUSIONS Poor integration of follow-up treatment in the continuum of psychiatric care leaves many individuals, particularly blacks, with poor-quality treatment. Culturally appropriate interventions that link individuals in inpatient settings to outpatient follow-up are needed to reduce racial-ethnic disparities in outpatient mental health treatment following acute treatment.
    Psychiatric services (Washington, D.C.) 04/2014; 65(7). DOI:10.1176/ · 1.99 Impact Factor
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: To assess the extent to which the observed racial disparities in cardiac revascularization use can be explained by the variation across counties where patients live, and how the within-county racial disparities is associated with the local hospital capacity. Administrative data from Pennsylvania Health Care Cost Containment Council (PHC4) between 1995 and 2006. The study sample included 207,570 Medicare patients admitted to hospital for acute myocardial infarction (AMI). We identified the use of coronary artery bypass graft (CABG) and percutaneous coronary intervention (PCI) procedures within three months after the patient's initial admission for AMI. Multi-level hierarchical models were used to determine the extent to which racial disparities in procedure use were attributable to the variation in local hospital capacity. Blacks were less likely than whites to receive CABG (9.1% vs. 5.8%; p<0.001) and PCI (15.7% vs. 14.2%; p<0.001). The state-level racial disparity in use rate decreases for CABG, and increases for PCI, with the county adjustment. Higher number of revascularization hospitals per 1,000 AMI patients was associated with smaller within-county racial differences in CABG and PCI rates. Meanwhile, very low capacity of catheterization suites and AMI hospitals contributed to significantly wider racial gap in PCI rate. County variation in cardiac revascularization use rates helps explain the observed racial disparities. While smaller hospital capacity is associated with lower procedure rates for both racial groups, the impact is found to be larger on blacks. Therefore, consequences of fewer medical resources may be particularly pronounced for blacks, compared with whites.
    PLoS ONE 07/2013; 8(7):e69855. DOI:10.1371/journal.pone.0069855 · 3.53 Impact Factor
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: Multimorbidity is increasingly prevalent in general practice, creating challenges for assessment and management. This paper aims to explore the methods used to assess the quality of care for primary care patients with multimorbidity. A systematic review of the published literature was conducted using major medical databases (Medline, Scopus, Embase and CINAHL). Measures were then categorised using the Donabedian framework. Twenty-seven studies were included. All of the process measures were disease-specific. Some non-disease-specific measures of outcome were identified, including functional outcomes, healthcare utilisation and patient-rated measures. There has been a reliance on measures of process and outcome for single conditions in the assessment of quality of care. A broader, more comprehensive range of measures of structure, process and outcome is needed to fully evaluate the care of patients with multimorbidity.
    Australian family physician 03/2014; 43(3):132-6. · 0.67 Impact Factor