Patients in contact with psychiatric care had a higher consumption of primary health care and of somatic outpatient and inpatient care. A subgroup identified as.
ORIGINAL PAPER
Patients with mental illness in primary health care. A long-term follow-up of health care utilization and contact patterns with psychiatric care Lars Hansson’, Kristina Brand Persson2and Lars Borgquisp
’ Department of Psychiatry, University of Lund,
Center for Primary Care Research, Uppsala University, Sweden.
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Received March 1996. Accepted January 1997.
Scand J Prim Health Care 1997;15:129-33. JSSN 0281-3432
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Objective Long-term follow-up of the use of health care services in patients with a mental illness identified in primary care. A 10-year follow-up of all health care utilization in five 1-year cohorts of patients with a mental illness identified in primary health care services of a Swedish health care district. Patients 1167 (408 males, 759 females) with mental illness. Results A total of 27.1% of the patients were in contact with psychiatric services during follow-up. The strongest associations with contact with psychiatric services concerned age (younger) and diagnosis (dependence, affective psychosis). Patients with a diagnosis of psychosis had the highest utilization of psychiatric services. Patients in contact with psychiatric
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The majority of patients with a mental illness are treated in primary care and a great number of studies have investigated psychiatric morbidity in primary care settings (1). Using the Goldberg and Huxley filter model as a framework (2) it has been shown that severity of illness is one of the major factors predicting passages through the filters from the community level to specialist services, but also a more severe social disability (3). Earlier studies have also shown that patients with a mental illness use more medical services than other groups of patients (4-6). However, long-term follow-ups of the utilization of care in representative cohorts of patients with mental illness identified in primary health care (PHC) are still lacking.
AIMS The aims of the present study were to investigate utilization of psychiatric services and other health care services during a 10-year follow-up in five 1-year cohorts of patients with a psychiatric illness identified in PHC. Specific research questions to be addressed were: 1. What proportion of the patients use specialist psychiatric services, and what are the characteristics of this subgroup? 2. What is the time-lag between identification of the psychiatric illness in PHC and contact with specialist psychiatric services?
care had a higher consumption of primary health care and of somatic outpatient and inpatient care. A subgroup identified as high consumers consumed 44% of the total health care resources used by the cohort. Conclusion The use of health care services was very skewed. Patients in contact with psychiatric services were more frequent users of other medical services.
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Key words: primary care, mental iliness, follow-up, utilization of health care.
Lars Hansson, DMSc, Department of Psychiatry, University Hospital, S-2.21 85 Lund, Sweden.
3. What are the patterns of psychiatric care for different diagnostic subgroups? 4. What is the relationship between utilization of psychiatric services and general health care services? 5. What are the characteristics of an identified group of high consumers of care?
MATERIAL AND METHODS Design The study was a 10-year follow-up of patients identified as psychiatric cases in a PHC district; it investigated all utilization of PHC, somatic care, and psychiatric care during the follow-up period. Setting and data collection The setting for the study was Tierp (population 20 OOO), a semi-rural community in mid-eastem Sweden, 60 km north of Uppsala. Since the early 1970s, PHC services have been concentrated in one health centre, family doctors working together with a paediatrician and part-time specialists. About 65% of all visits to a physician registered in the population in a given year are handled by the health centre. Individual-based data on health care utilization and prescribed drugs in the population have been routinely collected since 1972 and entered into a research data base at the Centre for Primary Care Research at Uppsala UniverScand J Prim Health Care 1997: 1.5
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L. Hansson et al.
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sity, which also covers specialist health care utilized by the residents of Tierp (7). Material The study population consisted of five cohorts of PHC patients, retrospectively selected from all patients visiting the health centre in 1976 to 1980. The inclusion criteria used were a) resident of Tierp during the selection year and the preceding three years, b) at least one physician visit in PHC with a main and/or subsidiary psychiatric diagnosis during the selection year, and c) no PHC physician visits with a psychiatric diagnosis during the preceding 18 months. Only residents who were 18 years of age or more at inclusion, alive at the end of follow-up, and who did not move from the health district during the follow-up were included. Categorization of patients Patients who had physician contacts in specialized psychiatric outpatient care or were admitted to psychiatric inpatient care during the follow-up period were labelled psychiatric cases. The disease classifications in use in the PHC setting during the study period have been official adaptations of ICD-8 for PHC (8). Patients were divided in affective psychosis, other psychosis, neurosis, dependence, psychosomatic disorder, and other nonpsychotic disorder. Patients were also divided in three age groups 18-39,40-55, and >55 years of age. The Service Consumption Score (SCS) devised by Lavik (9) was used to sum up the utilization of care. The SCS gives 1 point to one outpatient contact, 2 points to one day in daycare, and 3 points to one day in inpatient care. The sum of all contacts gives the total service consumption score. High consumers of care were defined as patients with a SCS in the 10th percentile of the total SCS. Statistics One-way AN0VA:s and the Kruskal-Wallis test were used in analyses of variance, and stepwise logistic regression models in finding predictors of contact with specialist psychiatric care and high consumption of health care. The statistical software used was SPSS (10).
RESULTS The final cohort consisted of 1167 patients (Table I). Patients with a diagnosis of psychosis constituted about 6% of the cohort, while the commonest diagnostic subgroups were neurosis (36.8%) and other non-psychotic disorders (35.7%). In total, 316 patients (27.1%) had at least one contact with psychiatric services during the follow-up. Considering care level, 16.8% were in contact with psychiatric outpatient care only, 2.1% were admitted to psychiatric inpatient care only, and 8.2% were in contact Scand J Prim Health Care 1997: 15
Table I. Sociodemographic and clinical characteristics of the cohort (n=1167). Sex Male Female Age group (years) 18-39 40-55 >55 Diagnosis
Affective psychosis Other psychosis Neurosis
Dependence Psychosomatic disorder Other non-psychotic disorder
n
8
408
759
35.0 65.0
424 336 407
36.3 28.8 34.9
44 25 429 28 224 417
3.8 2.1 36.8 2.4 19.2 35.7
with both. Table II shows characteristics of those passing to psychiatric care versus those who did not. A logistic regression procedure, with contact with psychiatric services as dependent variable, showed no differences with regard to sex, and that patients in specialist psychiatric care were younger (reference category >55 years) with an odds ratio (OR) for the age group 40-55 years of 2.1 and for the age group 18-39 years of 2.0 ( ~ 4 . 0 0 1 ) With . regard to diagnostic subgroups (reference category other non-psychotic disorders), patients with a dependence diagnosis (OR=9.5), affective psychosis (OR=5.5), other psychosis (OR=3.8), and neurosis (OR=2.1) were in contact to a higher degree with psychiatric services (p4.001). As to the time-lag between index contact in primary care and first contact with the specialist psychiatric services, 35% of the patients made contact with out-
Table II. Characteristics of patients in contacthot in contact with specialist psychiatric services during follow-up. Number and percentages given in the table. Specialist psychiatric service
Sex 'Male Female Age (mean, SD) Diagnosis Affective psychosis Other psychosis Neurosis Dependence
Psychosomatic disorder Other non-psychotic disorder
No contact (n=851)
(n=316)
Contact
295 (72.3) 556 (73.2) 49d7
113 (27.7) 203 (26.8) 4% 15
21 (47.7) 14 (56.0) 288 (67.1) 9 (32.1) 178 (79.5)
23 (52.3) 141 (32.9) 19 (67.9) 46 (20.5)
341 (81.8)
76 (18.2)
11 (44.0)
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Patients with mental illness in primary health centre
Table 111. Patients in contact with specialist psychiatric services and care level at first contact during the first year after index contact in primary care, for the 316 patients in contact with psychiatric services during the follow-up period. Number and percentages given. Outpatient services
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Diagnosis Affectivepsychosis (n=23) Other psychosis (n=l 1) Neurosis (n=141) Dependence (n=19) Psychosomatic disorder (n=46) Other non-psychotic disorder (n=76)
Inpatient services
Care Level
First contact 1st half-year
First contact 2nd half-year
Contact 1st half-year
2nd half-year
First contact outpatient care
First contact inpatient care
n (%)
n to/.>
n (%>
n (%)
n (%)
n (%)
8 (34.8) 4 (36.4) 38 (27.0) 5 (26.3)
3 (13.0)
5 (21.7)
9 (6.4) 2 (10.5)
6 (54.5) 17 (12.1) 4 (21.1)
3 (13.0) 1 (9.1) 4 (2.8) 2 (10.5)
4 (36.3) 110 (78.0) 9 (47.4)
8 (34.8) 7 (63.7) 31 (22.0) 10 (52.6)
11 (23.9)
9 (19.6)
2 (4.3)
1 (2.2)
40 (87.0)
6 (13.0)
21 (27.6)
0 (0.9)
6 (7.9)
1 (1.3)
64 (84.2)
12 (15.8)
0 (0.)
patient psychiatric services during the first year, and 16.5% of the patients were admitted to inpatient psychiatric services. There were no major differences between diagnostic subgroups with regard to the proportion of patients passing to psychiatric outpatient care during the first half-year after index contact (Table 111). The largest additional proportion in contact with psychiatric outpatient care during the 2nd half-year was in patients with a psychosomatic disorder, 19.6%. The differences between diagnostic subgroups in contact with psychiatric inpatient care during the first half-year were larger. While only 4.3% of patients with a psychosomatic disorder were hospitalized in psychiatric care during the first half-year, and an additional 2.2% during the second half-year, 54.5% of patients with a diagnosis of other psychoses were hospitalized during the first half-year, and an additional 9.1% during the next half-year. The majority of patients with a diagnosis of other psychoses and dependence had their first contact at the inpatient level, while patients in the other diagnostic subgroups had their first contact predominantly at the outpatient care level. The utiiization of outpatient and inpatient psychiatric care is shown in Table IV. There were significant differences between diagnostic subgroups at both levels. Affective psychosis and other psychosis patients had the highest utilization of both outpatient and inpatient psychiatric care. As to the utilization of somatic care, analyses of differences between patients in contact, or not in contact, with psychiatric care showed that the former were more frequent users of PHC (34222 vs 25217 visits, p
