Diabetes Prevention and Control Program costs for people with diabetes are estimated to be five times higher than for people without …
Diabetes and Mental Health Related Inpatient Hospital Utilization In Maine, 2004
January 2006
Maine Center for Disease Control and Prevention Division of Chronic Disease Diabetes Prevention and Control Program
This publication was supported by Cooperative Agreement Number U32/CCU122694 from the Centers for Disease Control and Prevention/Division of Diabetes Translation Its contents are solely the responsibility of the authors and do not necessarily represent the official view of the CDC
Maine Department of Health and Human Services
Maine Center for Disease Control and Prevention Formerly Bureau of Health th 286 Water Street 5 Floor 11 State House Station Augusta, ME 04333-0011
Brenda M Harvey Acting Commissioner
John Elias Baldacci Governor
Dora Anne Mills, MD, MPH Public Health Director Maine CDC Director
Diabetes and Mental Health Related Inpatient Hospital Utilization In Maine, 2004
John Elias Baldacci, Governor State of Maine Brenda M Harvey, Acting Commissioner Department of Health and Human Services Dora Anne Mills, MD, MPH Director Maine Center for Disease Control and Prevention Ron Bansmer, MBA Acting Director Division of Chronic Disease James F Leonard, MSW
Program Director Maine Diabetes Prevention and Control Program Lucinda A Hale, MS, RD, CDE Maine Diabetes Prevention and Control Program Katie Meyer, ScD, MPH Chronic Disease Epidemiology Consultant
Maine Diabetes Prevention and Control Program January, 2006
Table of Contents Executive Summary 1 Summary of Findings 1 Recommendations 2 Education of individuals 2 Education of personal care assistants 2 Education of case managers 2 Educate staff in long-term care 3 Introduction 4 Methods 6 Age and Gender Comparisons 6 Mental health appears to be prevalent among those with diabetes 6 Health Insurance8 Cardiovascular Disease CVD 9 Ambulatory Care Sensitive ACS Conditions10 Recommendations 11 Planned approach to care11 Education of individuals 11 Education of personal care assistants 11 Education of case managers 12
Executive Summary
Executive Summary
Diabetes is a chronic disease with no known cure The prevalence of diabetes has more than doubled in the last ten years in Maine and increases are projected to continue through 2025 according to national estimates Diabetes is an expensive disease; the direct medical costs for people with diabetes are estimated to be five times higher
than for people without the disease Although diabetes is not curable, it is manageable Significant advances have been made in the treatment and self-management of diabetes that dramatically reduce many costly complications Nine out of ten cases of diabetes are type 2, a form of diabetes that can be lifestyle related There is evidence that diabetes is more prevalent 14 in the mentally ill than in the general population 61 Diabetes is considered one of the most psychologically demanding of the chronic medical illnesses because it requires strict daily management of the treatment by the patients themselves2 The presence of psychiatric comorbidity can result in difficult clinical courses, because it may affect adherence to medication and selfcare regimes3
Summary of Findings
Diabetes is a frequent cause of hospitalization either directly, as a result of complications, or indirectly, as a contributor to other disease, such as cardiovascular Our analysis shows 16 of all hospital discharges in 2004 had a diabetes diagnosis mentioned Almost a third 30 of the records with a diabetes diagnosis also had a diagnosis of a mental health disorder Persons hospitalized and discharged with diabetes
and a mental health diagnosis were younger than those hospitalized with diabetes alone Fifty-six percent 56 of persons with both diabetes and a mental health diagnosis were less than 65 year old compared to 36 of those with diabetes and no mental health diagnosis The category of mental health diagnoses with the highest frequency was that of affective disorders, which includes depression and anxiety Severe and persistent mental illness eg, schizophrenia was the second most frequent principle discharge diagnosis Almost 18 of persons with diabetes and a mental health diagnosis were covered by MaineCare Additional data cited in this report also indicate that a large proportion of the individuals hospitalized with diabetes and a mental health diagnosis are insured by Medicare
Marion, L, et al Diabetes Management in the Context of Serious and Persistent Mental Illness 2002 by The Nursing Institute, College of Nursing University of Illinois at Chicago 2 Cox DJ, Gonder-Frederick L: Major developments in behavioral diabetes research J Consult Clin Psychol 60:628638, 1992 3 Blumenthal JA, et al Physiological and psychological variables predict compliance to prescribed exercise therapy in
patients recovering from myocardial infarction Psychosom Med 44:519527, 1982 Maine Diabetes Prevention and Control Program Page 1
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Executive Summary Medicare beneficiaries include persons 65 years of age and older, people under 65 with certain disabilities, and persons on dialysis with end-stage renal disease Persons with diabetes and a mental health diagnosis had a higher proportion of avoidable hospitalizations 45 compared to those with a diabetes diagnosis only 23 MaineCare was the primary payer in both accounting for 45 of the mental health group and 34 of the diabetes only group Diabetes increases the risk of cardiovascular disease Among those aged 45-64, a higher proportion of the diabetes and mental health group were hospitalized for cardiovascular disease 43 compared to those in the diabetes-only group 30
Recommendations
Diabetes requires daily management along with a planned-care medical program Reductions in complications and health care costs are dependent upon consistent control of blood glucose and medical treatment based on the chronic care model Efforts are underway in Maine to make the chronic care model a standard of care for people with chronic diseases
Medical care itself, however, is not the answer to diabetes control The majority of diabetes care occurs outside of the medical setting Increased selfmanagement skills are needed by people with mental health disorders and diabetes The following interventions are a good starting point and can reduce future complications through better control and management without being overly burdensome to the health care system:
Education of individuals
Encourage participation in a diabetes self-management education program DSME Our findings indicate that a large percentage of the diabetes-related hospitalizations were for diabetic keto-acidosis, which is preventable with appropriate disease management Therefore, special attention should be directed to the importance of self-blood glucose monitoring and appropriate treatment to avoid hospitalization for diabetic keto-acidosis Education on self-management to assist with weight control, regular physical activity, and tobacco cessation to prevent cardiovascular disease is also included in a DSME program
Education of personal care assistants
Education of personal care assistants who may assist individuals in boarding homes, group homes, or
residential facilities in the basics of meal planning, self blood glucose monitoring, medication administration, and appropriate physical activity The goal of this education would be to insure that personal care assistants are able to reinforce selfmanagement behaviors important to diabetes care
Education of case managers
Educate case managers to provide information on standards of medical care and appropriate therapy for people with diabetes This will help insure that the individual receives on-going essential medical care and is referred to appropriate community selfmanagement resources
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Executive Summary Encourage use of local community self-management resources such as attendance of individual at local community self-management resources for weight control, physical activity, smoking cessation, and stress reduction as appropriate to aid in diabetes management and reduction of development of complications4
Educate staff in long-term care
Educate staff in long-term care, residential facilities, and boarding and group homes about the prevention of diabetes complications, especially hyperosmolar coma Hyperosmolar coma is the
result of high blood glucose in individuals, particularly in those with type 2 diabetes Hyperosmolarity was noted as a common reason for hospitalization in the diabetes and mental health group This complication can be prevented with regular blood glucose monitoring to detect elevated blood glucose, prompt treatment of infection, and proper hydration5
McCulloch DK, Price MJ, Hindmarsh M, Wagner EH A population-based approach to diabetes management in a primary care setting: early results and lessons learned Eff Clin Pract 1998; 11 5 American Diabetes Association Diabetes Care American Diabetes Association: Clinical Practice Recommendations 2006, Hyperglycemic Crises in Diabetes, Supplement 1, January 2006 Maine Diabetes Prevention and Control Program Page 3
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Hospital Discharged for Diabetes and Mental Health by County
Introduction
Diabetes is a common and costly chronic disease Maines diagnosed diabetes prevalence has more than doubled in adults, from less than 34 in 1994 to more than 7 in 20056 The most recent Behavioral Risk Factor Surveillance System survey estimates 74,000 adults diagnosed with diabetes in the state7 Diabetes is on the rise worldwide; the World Health
Organization projects a 27 increase in diabetes prevalence in developed countries by the year 2025 and a 48 increase in developing countries8 The direct medical costs for people with diabetes are estimated to be five times higher than for people without diabetes9 In Maine, health care spending has increased and diabetes has been cited, as one of seven chronic diseases that contributes to increased health care costs10 Mental illness is also a common and costly chronic disease According to a report by the US Surgeon General, one in five adults has a diagnosable mental health disorder11 Nationally, mental illness is estimated to account for 73 of total health spending, excluding costs for Alzheimers and substance-abuse treatment12 Like diabetes, mental illness has been cited in the Maine State Health Plan as contributing to increased health care costs The state Medicaid program MaineCare has seen a dramatic increase in the amount of overall health expenditures dedicated to treating persons with mental illness: from 267 in 1996 to 372 in 200213 In addition, mental disorders made up the largest proportion 95 of hospital discharges 2004 when the frequencies of hospital discharges were
ranked by cause Diabetes is frequently co-morbid with other chronic diseases, which complicates the disease course and treatment Only one person out of six with diabetes has no other chronic conditions14 On average, a person with diabetes has 35 other chronic conditions15 Mental illness, especially depression, co-occurs with diabetes at high rates16 17 Studies have shown that people with mental illness and diabetes are at greater risk for complications18
CDC Behavioral Risk Factor Surveillance System Maine Behavioral Risk Factor Surveillance System: Diabetes Prevalence and Disease Management Analyses 2002-2004 Muskie School of Public Service 8 King, H et al Global burden of diabetes, 1995-2025: prevalence, numerical estimates, and projections Diabetes Care 1999 Apr; 224:650 9 Economic costs of diabetes in the US in 2002 American Diabetes Association 10 Governor Office of Health Policy and Finance Maines State Health Plan: A Road Map to Better Health DRAFT November, 2005, p15 11 US Surgeon General Mental Health: A report of the surgeon general 12 Ibid 13 Governor Office of Health Policy and Finance MaineCare Behavioral Health Care Expenditures: State Fiscal Years 1996-2002 March,
2005 14 Diabetes: The Impact of Multiple Conditions Partnership for Solutions June 2004 15 Ibid 16 wwwnews-medicalnet People with serious mental illness have higher rates of type 2 diabetes 17 National Institute of Mental Health Diabetes and depression 2002 18 Carney, C Diabetics with mental disorders at increased risk for diabetic complications Medical Care December, 2004
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Hospital Discharged for Diabetes and Mental Health by County Given this background, we sought to examine the co-existence of diabetes and mental illness in Maine We were particularly interested in learning about how the presence of mental illness might impact the management of diabetes and occurrence of complications, especially those that could be avoided through improved management Specifically, how does the existence of mental illness appear to impact the experience of having diabetes? One can address this question by comparing those with diabetes without mental illness to those with both diabetes and mental illness For the present report, we compare hospital discharge data for those discharged with a diagnosis of diabetes, but not of mental illness,
to those with both diabetes and mental illness diagnoses It should be noted that this is not equivalent to studying the population of Mainers who have diabetes to the population of Mainers with diabetes and mental illness Our analysis considered people as having diabetes and mental illness only if they received a discharge diagnosis of those conditions This raises the possibility of both underascertainment and of biased ascertainment and prevents our making statements about people with diabetes and mental illness general 
ly in the state In addition, we include in this early work only one year of data, which severely limited our ability to conduct subgroup analysis Despite these limitations, we believe that studying the hospitalization experience will yield valuable information about these populations We hope to gain insight into the experience of those with both diabetes and mental illness in a way that guides us to possible approaches for improved health This work fits into a larger goal of identifying opportunities to benefit persons with both diabetes and mental health disorders By comparing healthcare data of persons diagnosed with diabetes and a mental health disorder to those
with diabetes alone we can initiate an investigation into whether differences exist in disease management and the development of complications from diabetes If such differences exist, focused interventions, perhaps in the health system, could result in a healthier population
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Hospital Discharged for Diabetes and Mental Health by County
Methods
We used the Maine hospital discharge database for these analyses Non-federal Maine hospitals report 100 of discharge records to the Maine Health Data Organization MHDO who compile the data and release them to the Maine Center for Disease Control and Prevention From among the 160, 570 total discharge records for Maine residents in 2004, we identified 25,035 records with a diabetes diagnosis ICD-9-CM codes: 2500 2509listed on any of the ten diagnostic fields We then separated the 25,035 records into those with a diagnosis code of diabetes alone and those with discharges with of both diabetes and mental health ICD-9-CM codes: 2900-3199 In the following discussion, the diagnosis indicated first in the list of ten reported diagnoses is considered the principle diagnosis, the reason for
hospitalization All subsequent diagnoses fields 2-9 in the discharge record are considered secondary or contributing diagnoses
Age and Gender Comparisons
We compared the age distribution of persons discharged from the hospital with diabetes alone to those discharged with both diabetes and a mental health disorder Persons hospitalized and discharged with diabetes and a mental health diagnosis are younger compared to those hospitalized with diabetes alone Fifty-six percent 56 of persons with a mental health diagnosis were less than 65 year old compared to 36 of those with diabetes and no mental health diagnosis These findings suggest that those with both diabetes and mental illness may experience more diabetes-related hospitalizations at a younger age, compared to those with diabetes alone The groups differed slightly in their gender composition with the diabetes only group almost evenly divided between genders while the diabetes and mental health group had slightly more females than males This may reflect the fact that females tend to be more likely to receive a mental health diagnosis through treatment-seeking than men It does not necessarily imply that underlying mental illness
is more prevalent among females To the extent that males with mental illness were hospitalized without a receiving a discharge diagnosis of mental illness, they will be misclassified into the diabetes alone group
Mental health appears to be prevalent among those with diabetes
Diabetes is a frequent cause of hospitalization either directly, as a result of complications, or indirectly, as a contributor to disease Our analysis shows 16 of all hospital discharges in 2004 had a diabetes diagnosis mentioned Almost a third 30 of those records also had a diagnosed mental health disorder
Figure 1: Proportion of Diabetes Hospitalizations that are Diabetes Alone and Diabetes with a Mental Health Diagnosis
70
30
Diabetes Only Diabetes and a MH Dx
0
20
40
60
80
100
120
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Hospital Discharged for Diabetes and Mental Health by County
In figure 2 below we show hospital discharges for those diagnosed with both mental health and diabetes by county The largest number of discharges correspond with darker colors Aroostook and Kennebec counties stand out with respect to having greater numbers of discharges compared to county population
rankings
Figure 2: Distribution of Mental Disorders and Diabetes by County
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Health Insurance
Health Insurance
Persons with diabetes incur significant financial costs for supplies, health care, and other diabetes-related expenses Hartley, et al, pointed out in their 2002 study on diabetes and the rural safety net that high out-of-pocket costs contribute to sub-optimal management of diabetes19 Although Maine has one of the more comprehensive insurance regulations related to coverage of diabetes supplies and services PL 592, there is still significant expense for the person with diabetes in the form of co-payment and deductibles In table1 we show the payment source listed in the hospital discharge database for those discharged with a diabetes diagnosis alone and for those with both diabetes and mental health diagnoses The principal payer on the claim record was grouped into one of six payer types; Medicare, Medicaid, Veterans, Commercial, Self-pay, and Charity
Table 1: Comparison of Primary Payer Among Groups
Payer Medicare Medicaid Veterans Commercial Charity Self-pay
Diabetes Only 715 74 22 179 1 9
Diabetes and Mental Health
Diagnosis 621 175 21 163 3 17
In table 1 we see the largest differences between the two groups in proportions of Medicare and Medicaid For diabetes-only there was a greater proportion of Medicare as the primary payer, reflecting more persons 65 and older in the group Medicare is a health insurance program for people 65 or older, people under 65 with certain disabilities, and people with End-Stage Renal Disease20 Medicaid was the principle payer for greater numbers of persons with diabetes and a mental health diagnosis MaineCare Medicaid is a health insurance program available to certain low-income individual and families who fit into an eligibility group that is recognized by federal and state law21 Commercial and Veterans insurance proportions were similar between groups Charity and Self-Pay, although small numbers, do show a higher proportion attributed to those with a mental health diagnosis For other types of coverage, the percentage of diabetes-only and diabetes with mental health were fairly equally represented This shows that those discharged with diabetes and mental health were not only younger, but tendered to be from the lower-income segment of the young
population
Hartley D et al Diabetes and the Rural Safety Net Maine Rural Health Research Center Muskie School 2002 20 Center for Medicare and Medicaid Services wwwcmshhsgov/MedicareGenInfo/ 21 Ibid Maine Diabetes Prevention and Control Program Page 8
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Health Insurance
Cardiovascular Disease CVD
CVD is a major complication of diabetes and is responsible for the vast majority of deaths in people with diabetes People with diabetes are two to four times more likely to develop cardiovascular disease due to a variety of risk factors There was a higher proportion of people 45-64 in the mental health group that were hospitalized for CVD 43 compared to the diabetes only group 30 In the table below we show how the CVD hospitalizations within the two groups compare by age group at the time of hospitalization Among those hospitalized for CVD in the diabetesonly group a considerably larger proportion were 65 and older, while a larger proportion of the diabetes and mental health group was in the 45-64 year old age range Thus those diagnosed with both diabetes and mental health group appeared to have a larger portion of younger people hospitalized for cardiovascular diseases
Table 2:
Distribution of CVD Hospitalizations by Age Group
Diabetes Only
Diabetes and MH
Age Groups 18-44 45-64 65 Total 18-44 45-64 65 Total
Frequency 80 1089 2514 3683 69 444 517 1030
Percent 22 296 683 1000 67 431 502 1000
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Summary of Findings
Ambulatory Care Sensitive ACS Conditions
Ambulatory Care Sensitive ACS conditions are those for which hospitalization might be avoided through timely and adequate clinical preventive and primary care services For diabetes, there are several diagnoses considered ACSs : ketoacidosis, hyperosmolarity, and coma are the three diagnoses most 450 commonly included in short term avoidable 400 hospitalizations Persons with diabetes and a mental health 350 diagnosis had a higher proportion of avoidable 300 hospitalizations 45 compared to those with a diabetes diagnosis only 23 The age distributions, once again, 250 showed a higher proportion of 18-44 year olds 68 in the 200 diabetes and mental illness group compared to in the 150 diabetes only group MaineCare was the primary payer for 100 avoidable hospitalizations in both groups with 45 of the 50 mental health group and 34 of the diabetes only The
gender distribution was similar between groups with 55 of 00 the mental health group being female compared to 52 of the diabetes only
Figure 3: ACS by Group
450
230
Diabetes only
Diabetes and MH
Table 3: Ambulatory Care Sensitive Conditions Complication
Diabetes Only
Diabetes with other coma Hyperosmolarity Ketoacidosis
Age Group 0-17 29 32 155 135
Total 18-44 31 258 547 49 17 14 45-64 49 148 231 236 50 167 168 65 229 419 66 135 33 471 37 62 120 819 259 28 80 892
Diabetes with a mental health Dx
Diabetes with other coma Hyperosmolarity Ketoacidosis 53
742
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Recommendations
Recommendations
As these data indicate, it would be important to consider strategies to intervene as early as possible with individuals with diabetes and a mental health diagnosis Data also indicate a large percentage of individuals with both a diabetes and a mental health diagnosis have health insurance coverage through the MaineCare Program Recommendations for the Maine Care Program recipients include:
Planned approach to care
Planned care involves guideline implementation, support of self-management, and use of clinical information systems22
Planned care is associated with improvements in metabolic control23 Improved metabolic control leads to reductions in health care utilization and costs24 Attempts should be made to encourage the use of planned visits for the purpose of improving diabetes management Ample evidence, particularly for diabetes, demonstrates that planned visits are associated with improved outcomes25
Education of individuals
Education of individuals that encourage participation in a diabetes self-management education program26 DSME Our findings indicate that this population had a large percentage of hospitalizations for diabetic keto-acidosis, which is preventable Therefore, special attention to education on the importance of self-blood glucose monitoring to determine high blood glucose and appropriate treatment to avoid hospitalization for DKA is important27 Education on self-management to assist with weight control, regular physical activity, and tobacco cessation to prevent cardiovascular disease would also be included in the education at a DSME program
Education of personal care assistants
Education of personal care assistants to provide education for personal care assistants who may assist
individuals in boarding homes, group homes, or residential facilities in the basics of meal planning, self blood glucose monitoring, medication administration, appropriate
Montori, VM The Impact of Planned Care and a Diabetes Electronic Management System on Community-Based Diabetes Care Diabetes Care25:1952, 2002 23 Ibid 24 Wagner, EH, et al Effect of improved glycemic control on health care costs and utilization JAMA Apr 18; 285 15: 1963-4, 2001 25 Bodenheimer, T Planned visits to help patients self-manage chronic conditions American Family Physician 10,1,2005 26 American Diabetes Association Clinical Practice Recommendations, 2006 27 American Diabetes Association Diabetes Care American Diabetes Association: Clinical Practice Recommendations 2006, Hyperglycemic Crises in Diabetes, Supplement 1, January 2006 Maine Diabetes Prevention and Control Program Page 11
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Recommendations physical activity The goal of this education would be that personal care assistants would be able to reinforce these self-management behaviors important to diabetes care
Education of case managers
Education of case managers to provide information on standards of medical care and appropriate therapy
for people with diabetes This will help insure that the individual receives on-going essential medical care and is referred to appropriate community self-management resources Encourage use of local community self-management resources such as attendance of individual at local community self-management resources for weight control, physical activity, smoking cessation, and stress reduction as appropriate to aid in diabetes management and reduction of development of complications28 Additional data cited in this report also indicate that a large proportion of the individuals hospitalized with diabetes and a mental health diagnosis are insured by Medicare Medicare beneficiaries include persons 65 years of age and older, people under 65 with certain disabilities, and persons on dialysis with end-stage renal disease
McCulloch DK, Price MJ, Hindmarsh M, Wagner EH A population-based approach to diabetes management in a primary care setting: early results and lessons learned Eff Clin Pract 1998; 11 Maine Diabetes Prevention and Control Program Page 12
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